Provider Demographics
NPI:1407865371
Name:PALMER, SANDRA LOUISE (PA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LOUISE
Last Name:PALMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-1469
Mailing Address - Fax:585-922-1399
Practice Address - Street 1:1445 PORTLAND AVE
Practice Address - Street 2:SUITE 108/560
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3036
Practice Address - Country:US
Practice Address - Phone:585-922-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003581363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400002504Medicare PIN
NYT70165Medicare PIN
14277AMedicare ID - Type Unspecified